TENDON TRANSFERS AND UPPER LIMB DISORDERS Aws Khanfar, MBBS, MRCSI, MFSEM, CHSOrth, FEBOT.

TENDON TRANSFERS AND UPPER LIMB DISORDERS

Aws Khanfar, MBBS, MRCSI, MFSEM, CHSOrth, FEBOT

What is a tendon transfer?

• The tendon of a functioning muscle is detached from its insertion and reattached to another tendon or bone to replace the function of a paralysed muscle or injured tendon. The transferred tendon remains attached to its parent muscle with an intact neurovascular pedicle.

What is a tendon transfer?

• “Using the power of a functioning muscle unit to activate a non functioning nerve/muscle/tendon unit”.

• Tendon transfers work to correct:– instability– imbalance – lack of co-ordination – restore function by redistributing remaining muscular

forces

Indications• Paralysed muscle• Injured (ruptured or avulsed) tendon or muscle• Balancing deformed hand e.g. cerebral palsy or

rheumatoid arthritis• Some congenital abnormalities

General principles- Only justified in restoring functional motion of the

hand,

-. Patient factors• Age• Functional disabilities with poor non operative

prognosis • Ability to understand nature and limitations of surgery,

including aesthetic goals• Motivated to co-operate with post operative

physiotherapy

General principles-. Recipient site

• Tissue bed into which transfer is placed should be soft and supple

• Good soft tissue coverage• Stable underlying skeleton• Full passive range of motion of joints to be powered• Area to be powered must be sensate

General principles-. Donor muscle factors

Amplitude of the donor muscle ( TENDON EXCURSION)

General principlesPower of the donor muscle– Any transferred muscle loses at least one grade of

strength, so only Grade 5 muscles are satisfactory

General principlesOne tendon, One function– Effectiveness reduced in transfer designed to

produce multiple functionsSynergistic muscle groups are generally easier to

retrain– Fist group – wrist extensors, finger flexors, digital

adductors, thumb flexors, forearm pronators, intrinsics

– Open hand group – wrist flexors, finger extensors, digital abductors, forearm supinators

– Use of synergistic muscles tends to help retain joint balance

General principlesLine of transfer– Should approximate pull of original tendon if

possible– Acute angles should be avoided

Expendability– Transfer must not cause loss of an essential

function

General Post Operative Management

• Rehabilitation is equally important in tendon transfer success as surgical execution

• Rehabilitation / physiotherapy is essential in– Regaining joint mobility lost during splinting– Training tendon to glide in new course– Teaching patients to activate a new muscle to achieve a certain

function, which requires development of new neural pathways• The more that a patient notices a disability, the greater the

motivation, so the easier the retraining• Children are usually managed with static protocols or longer

protective phase

Basic Principles of Post Operative Rehabilitation

1. Pro tective phase• Begins at surgery and lasts 3 – 5 weeks• Objectives:-– Protective splinting– Oedema control– Mobilise uninvolved joints

2. Mobilisation phase• Begins when tendon healing is adequate for

activation (usually 3 – 5 weeks post op)• Objectives– Mobilise tendon transfer– Continue mobilisation of uninvolved joints to

prevent joint stiffness from disuse– Reinforce preoperative teaching and patient

education– Continue oedema control and protective splinting

Basic Principles of Post Operative Rehabilitation

3. Intermediate phase• Begins 5 – 8 weeks post operatively• Gradually increases hand activity and passive range of

motion exercises• Limited functional movements permitted4. Resistive phase• Beginning at 8 – 12 weeks• Tendon junctions are strong enough to withstand

increasing resistance• Therapeutic objective is to increase endurance and

strength of transferred muscles• Work related simulated tasks are begun to patient

tolerance

Radial Nerve Palsy• Wrist extension is critical for stability, which is

essential for grip and assisting the function of many tendons crossing the wrist

Tendon Transfers

• Well defined and highly effective, aiming to replace– Wrist extension– Finger extension– Thumb extension and abduction

• Standard

Radial Nerve Palsy

• Non-Operative Treatment– Splintage

– Maintenance of full passive ROM in all joints of the wrist/hands and prevent contractures

Radial Nerve Palsy

• Early transfers (“Internal Splintage”)– greatest functional loss is grip strength

PT to ECRB

FCU to EDC

PL to EPL

Common Upper limb disorders

• Symptoms:• Muscle/tendon problems : • Pain , Swelling ,Weakness• Nerve related :• Tingling/altered sensation , Weakness•

• Tendon problems: Dequervain’s • History: New, repetitive activity Pain over thumb side of the wrist Pain on making a fist, grasping or holding objects

• Examination Swelling Thickening Tenderness Freinklestein test

• Treatment Activity modificationNSAIDSplintage – thumb widely abductedSteroid Injection

• . Surgical Release

• Tennis/Golfers elbow• Incidence General population: 0.6% Tennis players: 9%Age: 35 and 50 years, with an equal distribution

between males and females Associated Rotator cuff problems: 20-40%

• EtiologyMultiple microtraumatic events Disruption of the internal structure of the

tendon and degeneration of the cells and matrix

• Presentation• Pain : outer aspect (Tennis elbow )of elbow/

inner aspect (Golfers) • Increases with activity and Lifting objects

Sometimes pain at rest• Palapation : Tenderness• Special test Resisted wrist extension , Elbow

flexion , Elbow Extension

• Non- Operative Treatment options• Topical NSAIDs• Oral NSAIDs• Orthotic devices• Physiotherapy

• Operative treatmentSurgery to repair the tendon

CTS

Incidence: 1-3 cases per 1000 persons per year Prevalence: 50 cases per 1000 persons aged in

their 30s and 50sWomen are affected 2-3 times more often

• Association of CTS in computer workers

• SymptomsPins and needlesPain The pain may travel up the forearm. Numbness of fingerDryness of the skin Weakness of muscles

• AnatomyContents:Nine flexor tendonsTendons Median Nerve

• Examination• Dry pulps• Wasting of Thenar muscles• Tinels

• Investigations• Nerve conduction test

• Treatment • Night splints• Surgical release

Shoulder Impingement syndrome

• Pain in shoulderIncreases with activityClicking sensation in shoulderPain with overhead activities/ reaching for seat

belt, wearing cloths

•Treatment

Pain medication Activity modificationPhysio ,To improve scapular position ,

Strengthen a specific group of musclesInjection into shoulderSurgery